PROJECT SUMMARY/ ABSTRACT Vascular access is one of the most challenging and expensive aspects of hemodialysis care. Use of an arteriovenous (AV) access (fistula or graft) is associated with improved quality of life and lower hospitalization and mortality rates. However, <20% of individuals in the US start hemodialysis with an AV access. Most prior efforts to improve AV access rates have focused on AV access creation after dialysis initiation. To date, few efforts to identify and address key barriers to AV access creation prior to dialysis initiation have been undertaken. Low rates of AV access creation may be attributable to a range of patient (e.g., knowledge, beliefs, fears, comorbidity), provider (e.g., knowledge, beliefs, practice patterns), and care process (e.g., fragmentation, long wait times) factors. Care process-based interventions have demonstrated only modest improvements in preemptive AV access creation, suggesting that such strategies on their own are not enough. Patient concerns such as fear, dialysis reluctance, and worries about body disfigurement and cannulation pain may limit the success of care process-based interventions. However, interventions that target both care process and patient-level barriers may improve AV access creation rates. To identify and break-down patient and care process barriers to AV access creation prior to dialysis initiation, we propose to: Aim 1) identify patients?, caregivers? and health care providers? perceptions of common barriers to AV access creation prior to dialysis initiation using qualitative research methods, and Aim 2) characterize the associations of care process factors and vascular access type at dialysis initiation using data from a large health care system. In Aim 3, we will conduct a pilot test of a novel intervention targeting key patient and care process barriers to pre-dialysis AV access creation to study intervention feasibility and potential to yield AV access use improvements. To accomplish these aims, we will leverage an existing chronic kidney disease care navigator program in a large health system and research infrastructure supported by a PCORI award. The findings of this research will lay the groundwork for a subsequent R01-equivalent application to fund a clinical trial to evaluate the effect of a patient and care process-focused AV access intervention on AV access use rates, quality of life and other clinical outcomes among individuals initiating hemodialysis in the US.